2. Objectives
• Participants will define medical
necessity.
• Participants will complete required
documentation relative to medical
necessity requirements.
• Participants will defend medical
necessity criteria in their continued stay
requests.
3. Federal standards of medical necessity
• “any medical or remedial services
(provided in a facility, a home, or other
setting) recommended by a physician or
other licensed practitioner of the healing
arts, for the maximum reduction of
physical or mental disability and
restoration of an individual to the best
possible functional level” (Federal Register, Section
1905(a)(13) of the Act and 42 CFR 440.130(d)).
4. Maine’s medical necessity
1.provided in an appropriate setting;
2.recognized as standard medical care, based on national standards for best
practices and safe, effective, quality care;
3.required for the diagnosis, prevention and/or treatment of illness, disability,
infirmity or impairment and which are necessary to improve, restore or
maintain health and well-being;
4. MaineCare covered service (subject to age, eligibility, and coverage
restrictions as specified in other Sections of this manual as well as
Prevention, Health Promotion and Optional Treatment requirements as
detailed in Chapter II, Section 94 of this Manual);
5.performed by enrolled providers within their scope of licensure and/or
certification; and
6.provided within the regulations of this Manual
5. Adams & Grieder:
• “Simply stated, the documentation of
medical necessity is the clear
demonstration that there is a clinical
need and that services provided are an
appropriate response.”
Treatment Planning for Person-Centered Care, Neal Adams, Diane M. Grieder,
ElSevier Academic Press, 2005.
6. What do you do (at work)?
• Use the next 2 minutes to brainstorm a
list of tasks you do at work most days.
7. What does Maine Care reimburse
for?
• On your list star all of the activities
Maine Care reimburses for.
8. The Maine Care regulations:
• Assessment
• Individual plan (ISP)
• Coordination/advocacy
• Monitoring
• Evaluation
9. Assessment
• “The case manager will coordinate a
comprehensive assessment of the child or
adolescent in consultation with team members
(professionals, providers, family or guardians,
and the child or adolescent) as necessary. The
appropriate professionals, acting within the
scope of their licenses, will complete the
clinical components of the comprehensive
assessment.” (Maine Care Regulations, section 13.12, p. 42)
10. Medical necessity starts with the
referral and the assessment
• The case manager should read the
assessment to determine:
– Eligibility criteria are met
– Treatment recommendations for case
management are noted in the summary
• Case management to do what?
11. Decision tree
• Eligibility criteria are met?
– Yes. Proceed.
– No. Do an addendum if the client meets eligibility,
but it’s not documented in the summary (ex., child
case management must be explicitly stated in the
summary).
• Case management role/tasks are defined in
the summary?
– Yes. Proceed.
– No. Do an addendum to indicate the needs and
indicate the role of case management in the
summary section
12. Assessment review
• Does this client qualify for child case
management?
• Do you have enough information to base
some ISP goals off of?
13. Individual Plan (ISP)
• “The case manager will coordinate
development of an individualized plan of care,
based on the comprehensive assessment. The
Individual Support Plan (ISP) is a holistic plan
involving all service providers and agencies. It
encompasses the respective plans developed
by each involved agency…” (Maine Care Regulations,
Section 13.12, p. 43)
14. The ISP is a service contract
• Who are you contracting with?
– Parents
– Other providers
– Children
– Maine Care
• What are you contracting for?
– Covered services
16. Limitations
• You only get paid for the covered
services listed on the ISP and referred to
in the assessment!
17. Review ISP and assessment
• Are the tasks listed on the ISP
reimbursable through Maine Care?
• Why or why not?
18. Progress notes
• Must relate to the ISP and indicate what the
case manager actively did during the time they
billed.
• If a consultation call was made:
– How long?
– To whom?
– For what?
– Outcome?
19. Home visit:
• When was it?
• Who was there?
• What was the purpose?
– “Scheduled visit” isn’t enough. “Scheduled visit for
review of client’s progress” is.
• What was the outcome?
– Is the client improving? Decompensating? No
change?
– Is there a change to the service plan?
20. Coordination/Advocacy
• “The case manager will provide coordination
and advocacy services, the purpose of which
is to ensure that the child or adolescent has
access to and utilizes the services and
resources identified in the ISP. Specifically,
the case manager will coordinate the multiple
providers of services identified in the ISP, will
ensure appropriateness of services, and will
advocate on behalf of the child or adolescent
and his or her parent or guardian.” (Maine Care
Regulations, Section 13.12, p. 43 - 44)
21. Monitoring
• “The case manager will provide monitoring
services to ensure full implementation of the
ISP. Monitoring will assess the child or
adolescent’s progress toward meeting
objectives outlined in the Individual Support
Plan and will be accomplished by an ongoing
in-person contact with the member and his or
her parent or guardian.” (Maine Care Regulations, Section
13.12, p. 44)
22. Evaluation
• “The case manager will provide evaluation services
quarterly to determine whether the Individual Support
Plan is appropriate and effective. If necessary, as part
of the evaluation, the case manager will convene the
Child and Family Team, other providers, and family
members for consultation. Following the evaluation,
the case manager will continue the plan as written,
modify the plan, revise the goals, or terminate
services, based on the results of the evaluation
process.” (Maine Care Regulations, Section 13.12, p.44)
23. Non-covered services
• “Habilitation services, which are health
and social services that encompass
training in intellectual, sensory, motor,
and affective social development.” (Maine
Care Regulations, Section 13, p. 88)
24. • Transportation
• Counseling and therapy
• Services provided while the child is in the
hospital or other inpatient setting
• Direct services reimbursable under other
sections of Maine Care
• Services provided by parents or other relatives
of a minor
